Hjärtsjukvårdens Nationella Kvalitetsregister Per Albertsson. Ordförande Sektorsrådet i Hjärtsjukvård
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NATIONELLA KVALITETREGISTER SWEDEHEART Pacemakerregistret Hjärtstoppsregistret Riks-svikt PAH-registret Auricula (Förmaksflimmer) SWEDEHEART= RIKS-HIA SCAAR Hjärtkirurgiregistret SEPHIA TAVI Ablacure (Ablationer)
190 variabler
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Kvalitetskontroll i realtid
Kvalitetsindex: Akuta åtgärder vid hjärtinfarkt
Kvalitetsindex: Akuta åtgärder vid hjärtinfarkt 8
Kvalitetskontroll i realtid
Kvalitetsindex: Akuta och sekundärpreventiva Åtgärder vid hjärtinfarkt
11 Presentationens namn Verksamhetsstyrning
FORSKNING
Forskning och betydelse för budget; Västra Götaland 1.6 million inhabitants, 17 % of the Swedish population Data from the SCAAR registry (Swedish Coronary Angiography and Angioplasty Registry) Consecutive PCI 2005-2013 5 PCI hospitals ~20 % of all data in SCAAR
RESULTS Propensity score adjusted Cox proportional hazards regression HR = 0.63, 95% CI 0.49 0.82, P <0.001
Heparin versus bivalirudin in patients with non ST-elevation acute coronary syndrome undergoing percutaneous coronary intervention - a report from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) Oskar Angerås 1, Sasha Koul 2, Måns Söderbom 3, Per Albertsson 1, Truls Råmunddal 1, Göran Matejka 1, Fredrik Scherstén 2, Jonas Oldgren 4, Stefan James 4, Bo Lagerqvist 4, Ole Fröbert 5, Hans Wedel 6, David Erlinge 2, Elmir Omerovic 1 1 Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden 2 Department of Cardiology, Lund University, Lund, Sweden 3 Department of Economics, University of Gothenburg, Gothenburg, Sweden 4 Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden 5 Department of Cardiology, Örebro University Hospital, Örebro, Sweden 6 Nordic School of Public Health, Gothenburg, Sweden
Results A d ju s te d o d d s r a tio 3 0 - d a y m o r ta lit y C o m pl e te ca s e 1.5 3 Im pu te d da ta s e t 1.35 In s tru m e n ta l va ri a bl e 1.1 4 0.0 0.5 1.0 1.5 2.0 2.5 F a v o u r s b iv a lir u d in F a v o u r s h e p a r i n
Anticoagulation therapy during PCI -- The rise and fall of bivalirudin at Sahlgrenska University Hospital Angerås O. 1, Völz S. 1, Odenstedt J. 1, Råmunddal T. 1, Petursson P. 1, Ioanes D. 1, Haraldsson I. 1, Dworeck C. 1, Libungan B. 1, Albertsson P. 1, Omerovic E. 1 1 Department of Cardiology, Sahlgrenska University Hospital, GOTHENBURG Background Bivalirudin has been shown superior to heparin and glycoprotein IIb/IIIa receptor inhibitors (GP IIb/IIIa) during percutaneous coronary intervention (PCI) in randomized studies of patients with acute coronary syndrome (ACS), i.e. ST segment elevation myocardial infarction (STEMI) and non-stemi. However recently, studies comparing bivalirudin to heparin in both non-stemi and STEMI have been presented questioning the superiority of bivalirudin ragarding mortality. This abstract aim to describe the usage of bivalirudin in patients with ACS undergoing PCI in one large centre in Sweden, Sahlgrenska University Hospital (SU), Gothenburg. Methods Data on patients, anticoagulation therapy used and reported complications was collected from SCAAR (Swedish Coronary Angiography and Angioplasty Registry). PCI procedures performed January 2010 January 2015 due to ACS were included in the analysis. Reported in-hospital bleeding events and 30 day mortality was analyzed for each year during the study period with logistic regression adjusted for indication, age, gender, prior myocardial infarction, prior PCI, prior CABG, treated hypertension, treated hyperlipidemia, vascular access site, cardiogenic chock and treatment of oral platelet inhibition prior to PCI. 100 Results Between 2010 and january 2015, 5,760 PCI procedures were performed in patients with ACS at SU. Bivalirudin was used as the primary anticoagulant in 3,302 procedures and heparin in 2,434 procedures. Background and procedural data is shown in table 1. A switch in anticoagulation strategy was seen from bivalirudin to heparin alone, see figure 1. In 2012 there were significantly less reported in-hostpital events than the other years during the period, see table 2. No difference was seen in 30 day mortality, data not shown. Heparin Conclusion In this single centre observational study, a treatment switch was seen from bivalirudin as the primary anticoagulation treatment to heparin alone from 2010 to 2015 with no negative impact on clinical events. Anticoagulation theparpy used (%) Table 1. Bivalirudin (n=3,302) Age (mean) 67 68 Female (%) 27 25 Heparin (n=2,434) 80 60 40 20 GPIIb/IIIa Bivalirudin Pretreated ASA (%) Pretreated P2Y12- inhibitor (%) Radial access site (%) Indication (%) 94 94 92 91 75 69 0 2010m1 2011m1 2012m1 2013m1 2014m1 2015m1 Unstable angina 8 22 Non-STEMI 24 47 STEMI 64 27 Use of heparin (%) 85 100 Use of GPIIb/IIIainhibitor (%) Cardiogenic shock (%) 6 12 4 2
Revision/ Kvalitetskontroll Hjärtinfarktvården granskas ur ett genusperspektiv Samarbete med kunskapscentrum för jämlik vård
Sannolikhet att förskrivas rekommenderad behandling
Långtidsmortalitet (kvinna vs man)
K-M estimated rate (% per year) All cause mortality 7 6 Clopidogrel 6.0 5 4 Ticagrelor 4.9 3 2 1 HR 0.82 (95% CI = 0.68 0.99), p=0.04 0 01 2 3 4 5 6 7 8 9 10 11 12 No. at risk Months Ticagrelor 4,2014,005 3,962 3,876 3,150 2,413 1,993 Clopidogr 4,2294,029 3,989 3,912 3,195 2,471 1,980 el
Instrumental variabel analys ticagrelor vs. clopidogrel RIKS HIA 2005-2014 Number of clusters (centreid_dc) = 97 Number of obs = 104470 F( 18, 96) = 89.23 Prob > F = 0.0000 Total (centered) SS = 2964.721585 Centered R2 = 0.1272 Total (uncentered) SS = 3054 Uncentered R2 = 0.1527 Residual SS = 2587.73922 Root MSE =.1574 Ticagrelor N=21550 Clopidogrel N=82920 Risk reduktion per 100 patienter = 0.13% Robust d_dead_30 Coef. Std. Err. z P> z [95% Conf. Interval] tica.0012612.001995 0.63 0.527 -.002649.0051714 d_age_hia.0012411.0000683 18.17 0.000.0011072.001375 d_gender -.0059918.0012947-4.63 0.000 -.0085293 -.0034544 d_diabetes.0129791.0015259 8.51 0.000.0099884.0159698 _Ismoking_s_1 -.0000218.0012845-0.02 0.986 -.0025393.0024958 _Ismoking_s_2.0060876.0013902 4.38 0.000.003363.0088123 _Ismoking_s_9.0280674.0040656 6.90 0.000.0200989.0360358 _Id_diagrup_2 -.0213634.0011857-18.02 0.000 -.0236874 -.0190395 d_resuscitated_cardiac_arrest.0780461.0035354 22.08 0.000.0711169.0849753 previous_mi.0032785.0009846 3.33 0.001.0013487.0052083 previous_pci -.0001791.0011285-0.16 0.874 -.0023909.0020327 previous_stroke.0164133.0026574 6.18 0.000.0112049.0216216 beta_blockers_discharge -.0199554.0030477-6.55 0.000 -.0259287 -.0139821 d_ace_a2_discharge -.010115.0009367-10.80 0.000 -.0119508 -.0082792 statins_discharge -.0455739.0062565-7.28 0.000 -.0578364 -.0333113 aspirin_discharge -.0055842.0034249-1.63 0.103 -.0122969.0011285 d_pci -.0174473.0025893-6.74 0.000 -.0225223 -.0123723 cardiac_shock.0091765.0019237 4.77 0.000.0054061.0129469 _cons.0318026.0090291 3.52 0.000.0141058.0494993